Stroke
Stroke: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Gregory A. Doyle
Cerebrovascular disease is the most common acute neurologic illness in the United States. Stroke is defined as a neurologic deficit involving the cerebral circulation that lasts more than 24 hours (1). Transient ischemic attacks (TIA) are deficits that resolve within 24 hours.
Approach
A. Stroke type can be described by circulation:
1. Carotid (hemispheric)
2. Vertebrobasilar (brainstem or cerebellar)
B. Stroke can also be described by cause (2):
1. Ischemic (85%): atherosclerosis with artery-to-artery embolization.
a. Cardiac
(1) Mural hypokinesis with thrombosis, myocardial infarction (MI), cardiomyopathy, atrial fibrillation (arrhythmia)
(2) Embolism from valvular heart disease (mitral most common)
(3) Septal abnormalities, including patent foramen ovale, especially in patients aged less than 60 years (3)
b. Hypercoagulable states: causes include antiphospholipid antibodies, deficiency of protein S or C, presence of antithrombin 3, oral contraceptives
c. Miscellaneous states include posttraumatic, artery dissection, vasculitis, drugs (cocaine, amphetamines), and fibromuscular dysplasia
2. Hemorrhagic (15%):
a. Hypertension: damages putamen, internal capsule, cerebellum, brainstem, corona radiata
b. Amyloid: lobar (cortical) hemorrhages in elderly
c. Vascular malformations
C. Special concerns. The differential diagnosis of stroke includes trauma (subdural hematomas), migraine headaches, focal seizures, metabolic disorders (especially hypoglycemia), Bell’s palsy, hyperventilation, hysterical conversion, and tumors. Computed tomography (CT) is valuable in ruling out these lesions.
History
A. Characteristics of the stroke. What is the duration of the deficit? Is the problem acute and lasting several hours? Impaired consciousness can occur in all types of stroke. More specific symptom may help localize the area of stroke:
1. Carotid circulation: symptoms of hemiplegia, hemianesthesia, aphasia, visual field defects, and loss of spatial function; occasionally, seizures, headache, amnesia, and confusion.
2. Vertebrobasilar circulation: symptoms of diplopia, vertigo, ataxia, facial paresis, Horner’s syndrome, dysphagia, dysarthria, quadraparesis
(a component of bilateral arms or legs), and crossed sensory symptoms (ipsilateral face and contralateral body). Cerebellar lesions often display headache, nausea or vomiting, and ataxia.
B. Past history. A history of trauma, migraine, vasculitis, seizure, and hypoglycemia could produce a condition that can mimic stroke. Fever or infection may suggest abscess. A prior history of stroke or TIA often precedes the presentation of a new stroke. A history of valvular heart disease, atrial fibrillation, or MI is relevant.
C. Risk factors. Patients need to be assessed for hypertension, cardiac disease (specifically atrial fibrillation), smoking, diabetes mellitus, hypercoagulable states, and hormonal therapy.
D. Hospitalization. This may be necessary for patients with transient or ongoing ischemic deficits. TIAs can herald a high-grade carotid stenosis or occult left atrial thrombus.
Physical examination (PE)
A. General examination. This should include vital signs (notably blood pressure), Mini-Mental Status Examination, and an examination of the eyes, including funduscopic. A screening neurologic examination of cranial nerves, coordination, muscle strength, sensation, deep tendon, reflexes, and gait is recommended.
B. Additional PE. Evaluate the heart (arrhythmia, mitral stenosis) and vascular system (carotid bruits), and palpate the scalp and neck (trauma and migraine) and superficial temporal arteries (arteritis).
Testing
A. Clinical laboratory tests. In most instances, laboratory tests are not helpful in the acute assessment. Laboratory tests that may be suggested by the clinical history and PE include blood sugar, coagulation studies (prothrombin, partial thromboplastin times), platelet count, antiphospholipid antibodies, protein S, protein C, antithrombin III, and toxicology screens (cocaine, amphetamines). C-Reactive protein can be of prognostic significance (4). Additional tests may be relevant, depending on the history and PE, including electrocardiogram, cardiac monitoring, electroencephalogram, and spinal tap.
B. Diagnostic imaging. In most instances, diagnostic imaging should include an emergent cerebral CT scan of the brain to rule out abscess, tumor, or hemorrhage. A magnetic resonance imaging scan is a better test for aneurysm, arteriovascular malformation, or tumors. Other tests can include transthoracic or esophageal echocardiogram, duplex carotid ultrasonography, cerebral angiography, and magnetic resonance angiography.
Diagnostic assessment.
The key to the diagnosis of stroke is the duration of neurologic event coupled with the signs and symptoms. The CT scan rules out other serious pathology that can mimic stroke. Specifically, laboratory tests can aid in the workup and are directed by the history and physical examination.
References
1. Schneck MJ. Acute stroke: an aggressive approach to intervention and prevention. Hosp Med 1998;34(1):11–28.
2. Graffagnino C, Itaachinski V. Stroke (brain attack). In: Dambro MR, ed. Griffith’s 5-minute clinical consult, 2nd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999:1014–1015.
3. Nendaz MR, Sarasin FP, Junod AF. Preventing stroke recurrence in patients with patent foramen ovale: antithrombotic therapy, foramen closure, or therapeutic abstention? A decision analytic perspective. Am Heart J 1998;135(3):532–541.
4. Muir KW, Weir CJ, Alwan W. C-Reactive protein and outcome after ischemic stroke. Stroke 1999;30:981–985.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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